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Balancing act

A revised version of what is arguably the NZVA’s most contentious policy was ratified last month. Bette Flagler reports on the NZVA’s position on the use of complementary and alternative veterinary therapies.

Callum Irvine says The Use of Complementary and Alternative Treatments by Veterinarians is the NZVA’s most contentious policy to date. The recently revised version was passed by the Standards Committee in July and ratified by the board in August. Callum adds that the approval of the policy represents a small paradigm shift in the profession.

“A policy like this shows that as a profession we are increasingly acknowledging and accepting diversity within the profession, as well as [showing] the changing societal expectations that influence the environment in which we work,” says Callum, who at the end of July stepped down from his role as NZVA Head of Veterinary Services.

“The evolution of the policy is fantastic,” says Liza Schneider, President of the NZVA's complementary medicines special interest branch (SIB). “It’s a step in the right direction for the NZVA to encourage the responsible use of complementary therapies.”

While some members of the NZVA disagree with the premise of complementary and alternative therapies, by passing this policy the NZVA and the profession at large acknowledge that having a policy for veterinarians to provide and/or advise on complementary and alternative treatments is in the best interests of animal welfare.

“We need to acknowledge that clients are going to search for and request various types of treatment,” says Callum. “As veterinarians, we are better placed than anyone else to provide balanced advice about medical care for animals, whether that is conventional, complementary or alternative, and to ensure that welfare is not compromised.”

The NZVA's Companion Animal Veterinarians Branch (CAV) supported this reasoning through its written submission: “We noted in our discussions on the topic that, regardless of the committee members’ personal opinions on complementary and alternative therapy, there was consensus on the benefit to animal welfare in having any therapy for an unwell animal managed by a veterinarian.”

Liza agrees. “There is currently a huge risk to animal welfare. Every place that deals with animals – except for many veterinarians – is talking about complementary therapy. As an animal owner, you’re kind of stuck, especially if your veterinarian belittles you for enquiring about it.”

The policy was developed in a careful and considered way, including a survey to explore members’ opinions on specific aspects of the existing policy. The survey was conducted in April and May 2017 and 232 surveys were returned. The policy was subsequently drafted and distributed to the SIBs.

“I received a good amount of diverse and thoughtful feedback and I used that to inform the development of the revised policy, including incorporating definitions and acknowledging that there can be harmful side effects if treatments are used irresponsibly. I genuinely felt that in spite of the strong opinions of some members on various sides, we could find a middle ground.

It was imperative that we acknowledged and respected different sides of the argument and that our goal was to reach a position that accepted conflicting views as reasonable and valid, that [respected the] rights of the clients, and that kept the welfare of the animal first and foremost. I believe we’ve achieved that,” says Callum.

Not all the SIBs were fully supportive.

“We believe that the NZVA should continue to promote evidence-based medicine as the basis for veterinary medicine,” says Richard Olde Riekerink, speaking on behalf of the NZVA's Industry SIB.

“This means a therapy is either effective or not effective. By definition, a ‘complementary’ or ‘alternative’ veterinary medicine does not fit in that philosophy. We believe that the NZVA should stick to that principle and not give the impression that it is okay [for veterinarians] to use unproven – and more often than not, ineffective treatments.”

The Industry SIB doesn’t insist that everything be subjected to a gold-standard, double-blind, controlled study, but instead that all treatments provided by veterinarians should be subjected to the same scrutiny. “For example, there are herbal medicines that are probably effective. But they should undergo the same scrutiny as any other treatment. Then it is evidence-based medicine.”

Richard says that while the first sentence of the policy is in agreement with this thinking, it then explains how the NZVA allows for complementary treatments. “To me that becomes a confusing message.”

Liza suggests that it’s time to open minds a bit. “This is helping to acknowledge that complementary therapies are a growing trend that are best used with veterinary input. This is part of the future of animal healthcare.

In the US there is currently a move to recognise veterinary herbal medicine as a specialty. Herbal medicine has a significant evidence base, with a number of studies on herbs illustrating their efficacy for treating various conditions published in well-known journals.

“As veterinarians, we’re perfectionists and we want to have data and trials that fit into a paradigm and that give us peace of mind. When other veterinarians use methods that are not part of that mainstream, people can feel threatened because it’s not ‘correct’ in their eyes,” she says.

“These types of therapy are then looked down upon, instead of the other option where people are more open and say, ‘Hey, our conventional approach has brought us to a dead end. Our client has nothing to lose by considering something outside the square’.”

“This policy,” says Callum, “puts the onus back on the veterinarian to ‘do no harm’. In all cases, veterinarians need to examine the evidence and, based on that, make judgements. If someone prescribes treatments that are misleading, they should be judged accordingly.

“The bottom line is that you must have client agreement and informed consent, ensure that you do no harm and protect animals’ wellbeing.”

The previous policy, says Liza, intimated that any veterinarian who used complementary therapies (especially homeopathy) was a charlatan. “It very much undermined the veterinarian’s ability to move forward or think outside the square. It limited innovation and undermined veterinarians who spend time and effort investigating and learning treatments they use because they see improved clinical outcomes in their patients. If we follow the Veterinary Council of New Zealand (VCNZ) guidelines, we can’t behave that way.”

Indeed, the new policy highlights the veterinarian’s responsibility under the code. Rather than the NZVA saying “You must or must not do something”, the policy says “You have a professional responsibility to make sure that what you recommend is supported by scientific evidence”.

Written feedback from the NZVA's Society of Dairy Cattle Veterinarians (DCV) echoed the importance of veterinarians prescribing according to evidence-based medicine: “Many of the products/ treatments used in complementary medicine do not have any trial work or evidence to support them. As veterinarians we must comply with the VCNZ Code of Professional Conduct, Veterinarians Act 2005 and Veterinary Medicines Act 1997.

Welfare and using products according to label claims are very important for veterinarians. There is a large risk to the veterinarian personally and to the profession by using some of these products (and anything off-label without evidence), so having some clarity like this from the NZVA is beneficial. While you could say the NZVA should not support the use of complementary medicines at all, there is a fair amount of public pressure, and it is better to have a clear policy for the public and for veterinarians who wish to use these treatments in their practices.

“Another important point to consider when using complementary treatments in production animals is the risk of residues. These animals are used to produce food – milk, meat, eggs and other products used and consumed by humans. Many of these complementary treatments have unknown withholding periods. There is a risk that complementary medicines may enter the food chain.”

Speaking on behalf of the epidemiology and animal health SIB, Mark Bosson emphasises the need to think carefully about this. “In the future, veterinarians will need to consider carefully not only treatment options, but health [promoting treatments] that would fall under alternative or complementary definitions. Some of these – for example, probiotics – have good science but do not require registration as veterinary medicines. When we use trace elements for deficiency, we discuss their treatment use, but, of course, they can be given as supplements to optimise health as well.

“The epidemiology branch supports the use of products of known efficacy and that are supported by food safety and animal welfare information, whether the products are conventional, complementary or alternative. Where data supporting a product is not strong, the veterinarian should provide balanced, factual information to clients. Where a product has no welfare or food residue risks, but has no or limited efficacy data, then the final decision on the use of the product should sit with the client; if there is doubt about the animal welfare and/or food safety risks of the product, the veterinarian should express this.”

Callum believes the policy challenges the profession to think about its attitudes to other things too. “As a profession we are becoming more open-minded, and this policy is a good start for us to trust each other’s discretion,” he says. “We can either reject [those] who think outside our comfortable box, or we can acknowledge that we all have the same degree and we seek out different areas of interest. Some of these treatments are useful in certain situations, and the bottom line is that the public is looking for alternatives in food and medicine. We can get on board or we can ignore it – but if we ignore it, we do so at our peril.